Untitled Document

THIS FORM MUST BE FILLED OUT & FAXED WITHIN 72 HOURS OF THE INCIDENT. AND MAIL US THE ORIGINAL WITH YOUR SIGNATURE AND KEEP A COPY FOR YOU RECORDS. ALL QUESTIONS MUST BE ANSWERED OR PROSECUTION MAY BE HAMPERED. THIS FORM IS NOT TO BE USED TO FILE A COMPLAINT IT IS ONLY TO BE USED IN AIDING AN INVESTIGATION.

Cecil County S.P.C.A. Inc.

P.O. Box 665

Chesapeake City, MD. 21915

410-398-9555 or 410-885-2342

www.cecilcountyspca.org

WITNESS AFFIDAVIT

Case # ___________

Name ____________________________________________________ Date of Birth____________________________________

Physical Address___________________________________________________________________________________________

Mailing Address____________________________________________________________________________________________

Phone Number_____________________________________________Alternate phone:__________________________________

DL #_______________________________________________________________________ State_________________________

Date of incident:__________________________________ Time of incident ___________________________________________

Location of incident:_________________________________________________________________________________________

Number of animals involved:____________

Description of animal (s)______________________________________________________________________________________

___________________________________________________________________________________________________________

Address where animal(s) live:__________________________________________________________________________________

Owner's name if known:_______________________________________________________________________________________

Describe the incident in detail

__________________________________________________________________________________________________________

_________________________________________________________________________________________________________

__________________________________________________________________________________________________________

_________________________________________________________________________________________________________

__________________________________________________________________________________________________________

I declare under penalty of perjury that the above details are true and correct to the best of my knowledge.

Signature _________________________________________________

Date _____________________________________________